Social Support
Lijun Song
Vanderbilt University
Joonmo Son
National University of Singapore
Nan Lin
Duke University
Key words: Social support, social network, social integration, social capital, social
cohesion
Song, Lijun, Joonmo Son, and Nan Lin. 2011. “Social Support.” Pp. 116-128 in The Sage
Handbook of Social Network Analysis, edited by John Scott and Peter J. Carrington.
London: SAGE.
1 Social support, a network-based social phenomenon, has become the focus of research
attention in the last three decades. As shown by a search of the Social Sciences Citation
Index for articles whose topic includes “social support” there were only three such articles in the 1950s and ten in the 1960s. The number rose to seventy-six in the 1970s.
Following this, on average per year, there were ninety-four such articles in the 1980s,
1394 in the 1990s and 2687 from 2000 to 2008. Social support has attracted burgeoning attention especially in health literature since the lack of social support is regarded as a potential fundamental cause of disease (Link and Phelan, 1995). As another search of the
Social Sciences Citation Index for articles with “social support” and “health” in their topics reports (see Figure 1), on average per year, there were less than six such articles from 1976 to 1989; the number increased to 445 in the 1990s and dramatically jumped to
1135 from 2000 to 2008. A few books explored the relationship between social support
and its health consequences (Caplan, 1974; Caplan and Killilea, 1976; Cohen, and Syme,
1985; Cohen, Underwood, and Gottlieb, 2000; Gottlieb, 1981 1983; House, 1981; Lin,
Dean, and Ensel, 1986). Many reviews from different disciplinary backgrounds have
surveyed the associations of social support with various health-related outcomes (Alcalay,
1983; Berkman, 1984, 2000; Coyne and Downey, 1991; Ell, 1984; Faber and Wasserman,
2002; Green, 1993; House, 1987; House, Umberson, and Landis, 1988; Kessler, Price,
and Wortman, 1985; Schwarzer and Leppin, 1991; Smith et al., 1994; Thoits, 1995;
Turner and Turner, 1999).
2 1800 1600 1400 1200 1000 Publications
of 800
600 400 Number 200 0
Year of Publication
Figure 1 Articles with “Social Support” and “Health” in topic: Social Sciences Citation
Index
Despite its substantial popularity and voluminous development, the term of social support still stimulates debates on its conceptualization and operationalization. Social support is confounded with other network-based but distinct social factors without clear discrimination, such as social cohesion, social integration, social networks, and social capital. Empirical results on its health returns are abundant but inconsistent across studies.
We thus begin this review by clarifying the nature and forms of social support. We then turn to its distinction from and association with other network-based factors. Next, we examine the operation of social support in the social production process of disease and illness. We conclude with a brief discussion of future research directions of social support research. Even though social support is a sociological phenomenon in nature, the existing literature on the topic has been dominated by epidemiologists, psychiatrists, and
3 psychologists, as House et al. (1988) observed two decades ago. Sociologists are
expected to play a crucial role in the advancement of future studies on social support.
CONCEPT OF SOCIAL SUPPORT: NATURE AND FORMS
The idea of social support has achieved great currency since the middle 1970s (for reviews see Barrera, 1981, 1986; Cohen, Gottlieb, and Underwood, 2000; Dean and Lin,
1977; Gottlieb 1981; Lin, 1986a; Thoits, 1982). Epidemiologist John Cassel, physician and epidemiologist Sidney Cobb, and psychiatrist Gerald Caplan made groundbreaking contributions to its popularity. Cassel and Cobb summarized accumulating empirical evidence on the promising impact of relational factors in health maintenance and promotion, and underscored social support as one such protective antecedent. Cassel
(1974, 1976) dichotomizes various social conditions relevant to health from a functionalist perspective: one category protects health, while the other one produces disease. He speaks broadly of social support as the first category, “the protective factors buffering or cushioning the individual from the physiologic or psychological consequences of exposure to the stressor situation” (1976: 113). Cobb (1974, 1976) uses a communication perspective. He (1976) conceives of social support as information, and classifies three types of information in terms of their functions: information leading a person to believe that he or she is cared for and loved (i.e., emotional support), is esteemed and valued (i.e., esteem support), and belongs to a network of communication and mutual obligation. Similar to Cassel’s definition, Cobb argues that the major protective role of social support lies in its moderating effect on life stress instead of its main health effect. In addition, psychiatrist Gerald Caplan (1974: 6-7) addresses the
4 concept of the support system as “an enduring pattern of continuous or intermittent ties that play a significant part in maintaining the psychological and physical integrity of the individual over time”, and lists three types of support activities: “The significant others help the individual mobilize his psychological resources and master his emotional burdens; they share his tasks; and they provide him with extra supplies of money, materials, tools, skills, and cognitive guidance to improve his handling of his situation.”
More attempts to conceptualize the substance of social support from different perspectives quickly followed. Dean and Lin (1977) consider social support as functions of primary groups that meet instrumental and expressive needs. Lin and colleagues later reconstruct social support at multiple levels of social networks as “support accessible to an individual through social ties to other individuals, groups, and the larger community”
(Lin et al., 1979: 109). Kaplan and colleagues (Kaplan, Cassel, and Gore, 1977: 54) point out that social support is the content of social ties (i.e., “the meanings that persons in the network give their relationships”), and is contingent on structural and interactional characteristics of social networks (i.e., anchorage, reachability, density, range, directedness, intensity, and frequency). Henderson (1977) applies attachment theory, and views social support as affectively positive social interaction with others under stressful conditions. Gottlieb (1978) lists four forms of informal social support derived from twenty-six helping behaviors: emotionally sustaining behaviors, problem-solving behaviors, indirect personal influence, and environmental actions. Wellman (1981) dichotomizes the content of social ties. He asserts that social support is only one type of content; the other is nonsupport. He lists five forms of social support derived from
5 twenty-one interactional strands: doing things, giving and lending things, help with personal problems, information help, and shared activities, values, interests, and interaction. He also highlights the variation of social support with network properties (i.e., ties strength, tie symmetry, density). Pearlin and colleagues view social support as “the access to and use of individuals, groups, or organizations in dealing with life’s vicissitudes” (Pearlin et al., 1981: 340). House and his colleagues define social support as one type of relational content, “the emotionally or instrumentally sustaining quality of social relationships” (House et al., 1988: 293). Berkman (1984) sees social support as the emotional, instrumental, and financial aid that is obtained form one’s social network.
More recently, Turner (1999) defines social support as social bonds, social integration, and primary group relations. Cohen and colleagues refer to social support as “any process through which social relationships might promote health and well-being” (Cohen et al.,
2000:4).
These different conceptualizations reflect an ambiguous construction of the social support concept. Despite the inconsistent framing, most of these efforts explicitly or implicitly converge on the relationship-based, assisting nature of social support. Based on the above review, we are more attracted to a strict synthetic definition of social support as the aid— the supply of tangible or intangible resources—individuals gain from their network members (Berkman, 1984; House, 1981). This definition narrows down social support to a specific relational content, separates its nature from its preceding social structures such as social networks and social integration, and eliminates its tautological assumption that social support protects against disease and what fosters health is social support. The
6 stretching of social support as general environmental factors (Cassel, 1976), relational
content (Kaplan et al., 1977; Henderson, 1977), or relational process (Cohen et al., 2000)
paves the way for diverse measurements and mixed evidence, and endangers the unique
theoretical value of social support. The functionalist framing of social support (Cassel,
1976; Cohen et al., 2000; Henderson, 1977) mixes social support with its consequences,
and overlooks the fact that social support does not always function in a positive direction
to meet needs, or to intervene between stressors and health. The disease- or stress-related
definition (Cassel, 1976; Cobb, 1976; Cohen et al., 2000; Henderson, 1977; Pearlin et al.,
1981) constrains the significance of social support within the health area, which would be
applicable to the production of other consequences and the general stratification process.
Most conceptualizing efforts also converge on multifaceted forms of social support.
Social support can be categorized in different ways. In terms of its content, for example,
social support can be divided into emotional support (liking, love, empathy); instrumental
support (goods and services); informational support (information about the environment); or appraisal support (information relevant to self-evaluation) (House, 1981). In terms of its degree of subjectivity, social support is dichotomized into perceived support and objective or actual support (Caplan, 1979). In terms of the role relationship between the
recipient and the donor (Dean and Lin, 1977; LaRocco, House, and French, 1980; Thoits,
1982), social support could be kin-based (e.g., parents, spouses, children, siblings, other
relatives) or nonkin-based (e.g., friends, neighbors, coworkers). In terms of its contexts, social support could be routine support within an ordinary situation or nonroutine support
within a crisis situation (Lin, Dean, and Ensel, 1986). Social support is thus a
7 multidimensional construct. Its exhaustive typology is beyond the scope of this chapter.
A cross-tabulation following the foregoing strategies produces thirty-two forms of social support. Also note that social support is traditionally used as a single directional concept, and refers only to support that egos receive from their network members. Some argue that social support is bidirectional (Pearlin, 1985; Wellman, 1981). Egos not only receive support from alters, but also give support to alters or reciprocate support with alters.
Providing or reciprocal support has received limited attention. We will focus on received support in the rest of this chapter.
DISTINCTION FROM OTHER NETWORK-BASED CONCEPTS
Theoretical Distinction
Social support thus rigorously conceived allows us to distinguish it from other network-
based but distinct preconditions of disease and illness such as social cohesion, social
integration, social network, and another recently popular construct, social capital. The
health consequences of these four factors have also been well documented (for reviews
see Berkman, 1995; Berkman and Glass, 2000; Berkman et al., 2000; Greenblatt, Becerra,
and Serafetinides, 1982; House et al., 1988; Kawachi, Subramanian, and Kim, 2008;
Kawachi and Berkman, 2001; Lin and Peek, 1999; Luke and Harris, 2007; Pescosolido
and Levy, 2002; Smith and Christakis, 2008; Song, Son, and Lin, forthcoming; Stansfeld,
2006). However, the distinction between social support and these factors tends to be
blurred in recent health literature. Some put social networks, social integration, and social
resources under the rubric of social support (e.g., Elliott, 2000; Lin, Ye, and Ensel, 1999;
Roxburgh, 2004; Turner, 1999). One recent fashionable trend is to subsume social
8 support together with social cohesion, social integration, and social network under the
popular umbrella of social capital (e.g., Carpiano 2006; Coleman, 1990; Putnam 2000;
Szreter and Woolcock 2004).
Such an entangled conceptualization jeopardizes the unique heuristic utility of each
concept, and confounds their causal relationships. To overcome this theoretical issue
scholars have attempted to distinguish them from each other (Berkman et al., 2000;
House et al., 1988; House and Kahn, 1985). We have made careful efforts to differentiate
them elsewhere (Song and Lin, forthcoming). To begin, social network is “a specific set
of linkages among a defined set of persons, with the additional property that the
characteristics of these linkages as a whole may be used to interpret the social behavior of
the persons involved” (Mitchell 1969:2). Its simplest form is a dyadic social tie. Social
network is not a theory but a perspective (Mitchell 1974). It provides guides to explore
various network properties, their causes, and consequences. Network properties may be
objective, including tie attributes such as tie strength and relational contents; structural
attributes such as network size; and compositional attributes such as network members’
characteristics. They may also be subjective, such as network norms. Specific theories
such as social cohesion, social integration, social capital, and social support are derived
from the network perspective (Berkman et al., 2000; Lin and Peek, 1999; Pescosolido
2007). Social cohesion is the degree of social bonds and social equality within social networks, indicated by trust, norms of reciprocity, and the lack of social conflict
(Kawachi and Berkman 2000). Social integration is the extent of participation in social networks, indicated by active engagement in social roles and social activities, and
9 cognitive identification with network members (Brissette, Cohen, and Seeman 2000).
Social capital is resources embedded in social networks, measured as structural positions of one’s network members (Lin 1999a).
Thus conceived (see Figure 2), social support is separated from its structural contexts
(Dohrenwood and Dohrenwood, 1981; House and Kahn, 1985; Lin et al., 1999). Social cohesion as norms is more upstream in the causal chain, and may regulate properties of other network-based factors. Social integration is positively associated with the quality and quantity of social capital and social support by maintaining old relationships and establishing new relationships. Social capital is a source of social support since network members’ resources are drawn for various supportive purposes. Social support may therefore be conceived as a downstream factor subsequent to the operation of social cohesion, social integration, and social capital, and other network features. Certain indicators of social integration, social capital, and other network characteristics may act as proximate measures of social support. The relationship between these network-based factors is indeed reciprocal and dynamic from a longitudinal perspective. For example, the activation process of social support, either satisfying and effective or unsatisfying and ineffective may redirect the degree and form of social integration, reconstruct the availability of social capital, and finally reshape the strength of social cohesion. After clarifying the meaning of these terms, we turn to empirical evidence on the network contingency of social support. Little attention has been paid to the relationship between social cohesion and social support. We review a few studies on the associations of social integration, social capital, and other network features with social support.
10
Social Social Integration Capital
Social Social Cohesion Support
Figure 2 A Conceptual Model of Social Support and Its Network-Based Sources
Empirical Evidence: The Network Contingency of Social Support
Social integration fosters the social production of social support. Lin and colleagues (Lin
et al., 1999) use a community sample of adults. They measure social support based on
forty items, and derive four latent factors to respectively indicate perceived instrumental
support, actual instrumental support, perceived expressive support, and actual expressive support. As they report, social integration (or participation in community organizations,
in their own words) directly leads to more actual instrumental support, indirectly
increases all types of support through expanding network size (i.e., the number of weekly
contacts), and indirectly produces perceived and actual instrumental support by
increasing the chance of the presence of an intimate relationship. Seeman and Berkman
(1988) analyze a community sample of older adults. Two types of perceived support,
instrumental (i.e., help on daily tasks) and emotional (i.e., talking over problems and decision making), are both positively associated with network size; number of face-to-
11 face contacts; number of proximal ties; having a confidant relationship; and direct contacts with children, friends, and relatives. One specific form of social integration, religious participation, and its linkage to social support has received much attention.
Ellison and George (1994) employ a community sample of adults. Their findings vary with the measurements and the types of actual support. They presented a list to respondents of thirteen types of support, and asked whether their network members ever offered these types of support. If each type of received support is measured separately as dummy variables, the frequency of religious attendance is positively associated with the supplies of four out of thirteen types of support: gifts or presents, business or financial advice, house maintenance and repair tasks, and running errands. When they measure received support as a summed score ranging from zero to thirteen, the frequency of religious attendance increases the variety of received support only indirectly through expanding the size of networks (i.e., number of nonkin ties, in-person contacts, and telephone contacts). Nooney and Woodrum (2002) focus on religious participation and church-based support. Using a national sample of adults, they find that the frequency of church attendance is positively associated with perceived support from their congregations. Taylor and Chatters (1988) investigate a national sample of black
Americans, and report that the frequency of church attendance expands the chance of receiving support from people in the church. In a study of a national longitudinal data of adolescents (Petts and Julliff, 2008), social support (i.e., how much adults, teachers, parents, and friends care about them; and how much their family understands them, cares about them, and has fun together) explains away the effect of religious participation on depression.
12
The positive linkage of social capital to health and economic well-being has been documented (Lin, 1999b; Song et al., forthcoming). As social capital researchers generally assume, social capital contributes to various returns by providing a higher level of different forms of social support such as information, influence, social credential, and reinforced identity (Lin, 2001). However, direct examinations of the impact of social capital on social support are very limited if we operationalize social capital strictly as structural positions of network members (Lin, 2001). Empirical results are also mixed.
One study examines the relationship between social capital and informational support
(Lin and Ao, 2008). It employs a national sample of currently or previously employed adults between twenty-one and sixty-four years of age and captures informational support by asking respondents whether they received job information at the time they started their current job. They map positional network through the position generator that asked respondents to identify contacts, if any, in each of twenty-two occupational positions at the time they started their current job. Social capital is derived from three indicators of positional networks: range (i.e., the difference of the highest and lowest prestige scores among the positions that each respondent could access), extensity (i.e., the number of different positions each respondent could access), and upper reachability (i.e., the highest score among accessed positions). They find a significant positive effect of social capital on the receipt of job information. Another study (Wellman and Wortley, 1990) collected information on twenty-nine respondents’ active network members in the East York section of Toronto, the total of which is around 335. It finds no association between network members’ socioeconomic positions (i.e., education, employment status, and
13 occupational status) and five indicators of actual support (i.e., emotional aid, major
services, small services, financial aid, and companionship). In addition, one study
explores the influence of social capital on actual support in a natural disaster context
(Beggs, Haines, and Hurlbert, 1996). The authors interviewed residents in two
communities after Hurricane Andrew in Louisiana and collected information on their
core networks prior to the disaster and on their actual support as well as support from
formal organization during disaster recovery. They measure eleven network
characteristics. Among them, the proportion of alters with a less than high school
education reflects structural locations of network members, and is the most proximate
indicator of social capital. That proportion is positively associated with the receipt of
informal recovery support. This finding seems to disconfirm our previous causal
argument on the positive association of social capital with social support. As the authors
explain, that finding is consistent with previous disaster studies. The underlying rationale is that individuals with less education may possess disaster-relevant occupational skills.
Such a finding implies that the function of social capital in the social distribution of social support varies across social contexts.
Apart from social integration and social capital, other network features also shape the process of social support. Haines and Hurlbert (1992) study a community sample of adults. They measure three indicators of perceived support: instrumental (i.e., having enough people to get help), companionship (i.e., having enough people with whom to socialize), and emotional (i.e., having enough people to talk to). The average number of contents per tie decreases instrumental support only for women; the proportion of kin
14 among alters increases instrumental support only for men; and density among alters increases companionship and emotional aid for men only. Wellman and Wortley’s East
York study (1989) observes that various forms of actual support vary with kinship relations. Parents and adult children offer higher levels of emotional aid, services, and financial aid; siblings especially supplement the provision of services; and extended kin are least supportive and less companionable. They further report (Wellman and Wortley,
1990) that stronger ties, measured as a higher degree of intimacy and voluntary interaction within diverse contexts, supply wider support and offer more emotional aid, small services, and companionship, and that physically accessible ties tend to provide services. They do not find significant associations of actual support with frequency of contact, group’s interconnections, and positional similarity between egos and network members. A more recent study (Plickert, Côté, and Wellman, 2007) investigates determinants of reciprocal exchange of emotional support, minor services, and major services. It reports significant associations between the giving and receiving of emotional support, the giving and receiving of minor services, and the giving and receiving of major services. It also finds partial evidence that giving one type of resource is associated with getting other types of resources in turn. Being a neighbor, a parent, or an adult child is positively associated with reciprocal support of major and minor services. The number of ties is positively associated with reciprocal emotional support. Tie strength does not exert a significant effect. We next review the theoretical and empirical evidence for the role of social support in the social production of disease and illness.
HEALTH RETURNS TO SOCIAL SUPPORT
15 Theoretical Modeling
Social support initially received research attention only as a buffer in the association of stressors with mental health (Cassel, 1976; Cobb, 1976; Kaplan et al., 1977). Most individuals have limited personal capital. When encountering undesirable life events they are expected to use social capital (i.e., personal capital of their network members) to supplement their personal capital through the process of social support. This process may reduce the negative health effects of stressful life events. In the last three decades diverse models linking social support to health have been developed (Barrera, 1986; Berkman,
2000; Cohen, Gottlieb, and Underwood, 2000; Dohrenwend and Dohrenwend, 1981;
Ensel and Lin, 1991; House et al., 1988; Lin, 1986b; Thoits, 1982; Wheaton, 1985). Most of these modeling efforts focus on the health functions of social support in the stressor- distress framework. We attempt to summarize these efforts, extend them beyond that framework, and focus on the crucial operation of social support. From a social causation perspective, social support has four major roles in the production of health: main effect, mediating effect, indirect effect, and moderating effect. The main effect hypothesis states that social support can protect health net of other social preconditions. In other words, social support adds a unique explanatory power to the social etiology of health and illness.
Personal capital such as socioeconomic status is a fundamental cause of disease and illness (Link and Phelan, 1995). Therefore social support, the use of personal capital from network members, is expected to exert a direct health effect as well. The mediating effect hypothesis argues that social support may act as an intermediate variable, and intervene in the relationship between its precursors and health consequences. As mentioned earlier, other network-based factors such as social integration or social capital may exert positive
16 health impacts through strengthening social support. Personal resources such as socioeconomic status may have similar indirect health effects by determining the quality and quantity of social support. Stressors could play similar roles by either triggering the use of social support or diminishing its availability. The indirect effect hypothesis holds that social support may prevent disease indirectly by shaping other health risk factors, such as health behaviors, psychological resources, and the physiological system
(Berkman et al., 2000; House et al., 1988). Also, as the prominent job search literature in the area of social stratification assumes (Lin, 2001), social capital advances socioeconomic status attainment through the provision of social support. In this context, social support may exert an indirect health effect by increasing socioeconomic positions that are fundamental causes of disease and illness (Link and Phelan, 1995). The moderating effect hypothesis assumes that social support may mitigate or exacerbate the health effects of other risk factors. For example, disadvantaged individuals with lower personal capital may be more motivated to use social support in the protection of health.
In this case social support equalizes the inequality effect of personal capital. On the other hand, advantaged individuals may invest more resources in social networking, and may be able to use social support more successfully and more efficiently in their access to health resources. Social support could thus intensify the inequality effect of personal capital. Take the stress paradigm as another example. Social support may ameliorate the negative health effect of stressors by helping individuals successfully deal with undesirable life situations. It may also enlarge that negative effect on mental health especially, for example, by increasing the recipients’ psychological burden. Furthermore, from a social selection perspective health status may also influence the availability and
17 activation of social support (Thoits, 1995). There are two possibilities. On one hand,
poorer health may provoke the recognition and mobilization of social support. On the
other hand, poorer health may produce lower perceived and received social support
because of resultant higher needs for help, or because of its constraint on social
interaction with network members. Finally, as mentioned earlier, the mainstream social
support literature focuses on received support rather than providing support. The
foregoing theoretical modeling applies to received support. Some have argued for the direct and mediating effect of providing social support on health (Krause et al., 1999).
Supporting others may protect health directly through fostering personal control, sustaining a sense of self-worth, maintaining network ties, and improving immune functioning. It may also mediate the relationship between religious practice and health.
Next, we selectively review recent empirical evidence. We include only quantitative
studies using a noninstitutionalized sample of adults due to limited space and for the
purpose of stronger generalizability and more rigorous theoretical examination (Dean and
Lin, 1977). We also choose to highlight varying specifications of social support by
summarizing these studies one by one.
Empirical Evidence
Most studies explore received support. They employ data from cross-sectional surveys
and report inconsistent evidence. The health impact of perceived support receives much
more attention, and most studies use data from community surveys. In one study (Ross
and Mirowsky, 1989), perceived support (i.e., having someone to talk to or run to for
18 support) has a main negative effect on depression. It mediates some positive effects of
marriage and education but not those of family income or race/ethnicity. Perceived
support also interacts in a complementary manner with the level of control. The positive
depression effect of a low level of control is significantly reduced by access to a higher level of perceived support. Another study (Jackson, 1992) examines four-item perceived spouse support, and four-item perceived friend support. The relationship of support with depression depends on the sources of support and the nature of stressors. Spouse support reduces the depression effect of all five kinds of stressors (i.e., marital strain, parental strain, work strain, economic strain, and physical health), while friend support plays similar roles only for three kinds of stressors (i.e., martial strain, economic strain, physical health strain). Roxburgh (2006) investigates perceived support from co-workers and partners. Partner support exerts a main negative effect on depression for both gender groups, and does not have moderating effects. Co-worker support has a main negative effect on depression only for men, and buffers the positive depression effect of the stressor time pressure only for men. Turner and colleagues (Turner and Lloyd, 1999;
Turner and Marino, 1994) measure perceived support from partners, relatives, friends, and co-workers based on twenty-five items. Perceived support has main negative effects on both depressive symptoms and major depressive disorder. It mediates some effects of gender, age, marital status, and socioeconomic status on depressive symptoms, but does not mediate their effects on major depressive disorder. It does not moderate the linkages of stressors, age, sex, marital status, and socioeconomic status to both measures of mental health. Haines and Hurlbert (1992) use three indicators of perceived support: instrumental
(i.e., having enough people to get help), companionship (i.e., having enough people with
19 whom to socialize), and emotional (i.e., having enough people to talk to). Among them, only companionship exerts a main negative effect on distress. Only this indicator buffers the effect of stressors. Landerman and colleagues (Landerman et al., 1989) measure perceived support (e.g., the frequency of feeling lonely, feeling understood, feeling useful, feeling listened to, feeling one has a definite role, knowing what is going on with family and friends, and talking about problems) and satisfaction with social support. The negative interaction effects of those two indicators with life events on depression are significant in linear probability models but not in logistic regression models. Elliott (2000) uses two indicators of social support: emotional support (i.e., presence of a confidant) and social integration (i.e., frequency of social interaction). Both types of social support reduce depressive symptoms and protect physical health, but only for residents of higher-
SES neighborhoods. It is speculated that disadvantaged neighborhoods are less likely to foster social interactions between residents, and residents there are less able to offer support.
Four studies investigate perceived support using national samples. Gorman and
Sivaganesan (2007) report that social support (i.e., the frequency of getting social or emotional support) does not exert a main effect on both hypertension and self-reported health. Ferraro and Koch (1994) measure perceived emotional support based on a four- item scale (i.e., feeling loved, listened to, demanded, and criticized). This indicator has a direct positive effect on health status (i.e., subjective health, chronic conditions, activity limitation) for both black and white respondents. In contrast, another study (Lincoln,
Chatters, and Taylor, 2003) reports racial/ethnic differences. Their latent social support
20 factor is derived from three indicators (i.e., the extent to which respondents feel that relatives understand the way they feel, appreciate them, and can be relied on for help).
Social support exerts a main effect on psychological distress only for African Americans.
It mediates the effect of personality only for African Americans in that neuroticism decreases social support. It has an indirect negative effect on psychological distress only for whites in that it increases personal control, which decreases distress. Furthermore,
Ross and Willigen (1997) analyze two national data sets simultaneously. Both data sets have information on perceived emotional support (i.e., having someone to turn to for help and talk to), and one on perceived instrumental support (i.e., having someone to help with daily tasks and care in sickness). Social support as a sum of emotional and instrumental support in one data set has a main negative effect on four forms of psychological distress such as depression, anxiety, malaise, and aches and pains. In another data set social support as emotional support exerts a similar effect on all outcomes except for aches and pains. They fail to find evidence from both data sets for social support as a significant mediator between education and distress.
A few studies examine both perceived and actual support. Wethington and Kessler (1986) use a national sample of married adults. They have one indicator of perceived support
(i.e., the presence of someone to count on for help), and six indicators of actual support: support from providers, support from spouse, support from close relatives, support from others, emotional support, and instrumental support. For those experiencing undesirable life events, perceived instead of actual support has a direct negative effect on
21 psychological distress. Actual spouse support exerts an indirect effect by increasing perceived support.
Lin and colleagues also examine both perceived and actual support in three cross- sectional studies. One study (Lin et al., 1979) uses a community sample of Chinese-
American adults. Social support is measured by a nine-item scale (i.e., interaction with friends, neighbors, people nearby, and the subcultural community, and feelings about the neighborhood, community, and workplace). It has a main negative effect on psychiatric symptoms. It does not moderate the effect of stressors. Another study (Lin et al., 1999) distinguishes two components of social support: structural support and functional support.
It measures three layers of structural support: belonging relationship (i.e., participation in seven types of formal organizations), bonding relationship (i.e., the number of weekly contacts), and binding relationship (i.e., the presence of an intimate tie). It uses forty items of social support from which four latent factors are derived: perceived and actual instrumental support, and perceived and actual expressive support. Among these indicators, bonding and binding relationships as well as perceived expressive support and actual instrumental support exert main negative effects on depression. Three layers of structural support also have indirect effects on depression by producing actual instrumental support, and the bonding relationship exerts an indirect effect through enhancing perceived emotional support. The third study (Lin, Woelfel, and Light, 1985) asked respondents to identify their most important life event in the last six months, then asked them about people they interacted with following that event. This collected information on respondents’ support networks. The study measures social support in two
22 ways: the strength of tie and the homophily between egos and helpers, assuming that such indicators capture the quality of social support. As the authors observe, strong ties decrease the negative effect of undesirable life events on depression but only for those in
a stable marital status. Age and educational homophily reduce depressive symptoms only
for the married, while occupational homophily exerts a similar effect only for the
unmarried.
Longitudinal studies are limited and also report mixed evidence. In one study of a two-
wave community sample (Thoits, 1984), stable emotional support (i.e., the presence of an intimate relationship) over time directly reduces the level of anxiety and depression at
Time 2. It does not interact with stressors. In another study of a two-wave community sample (Pearlin et al., 1981), emotional support (i.e., the presence of someone who provides understanding and advice, intimate exchange with spouses) does not have a main effect on changes in depression over time while decreasing economic strain and increasing mastery. It also does not moderate the relationship between the stressor (i.e., job disruption) and depression. One study uses a four-wave community sample
(Aneshensel and Frerichs, 1982). Its latent variable of social support is derived from three measures: number of close friends, number of close relatives, and received socioemotional and instrumental assistance. As it reports, current social support has a main negative effect on current depression at Time 1 and Time 4. Current social support also has indirect effects on subsequent depression as a result of the impact of current depression on subsequent depression over time. Depression does not seem to influence the social support factor over time. Current stressors result in a higher level of current
23 social support at Time 1 and Time 4, which may imply that stressors trigger the use of
social support.
Lin and colleagues (Ensel and Lin, 1991; Lin, 1986b; Lin and Ensel, 1984, 1989; Tausig,
1986) collected a three-wave community sample. Three of their studies use the first two
waves of data. One (Lin, 1986b) measures social support as a latent variable derived from
thirty-nine items covering community support, network support, confidant support, and
instrumental-expressive support. Social support thus measured has a main negative effect
on depression and its change over time. It mediates the effect of prior undesirable life
events, which indirectly increase depressive symptoms by decreasing social support. It also exerts an indirect effect by suppressing current life events. There is no evidence for
the interaction of social support with undesirable life events. In the other two studies (Lin
and Ensel, 1984; Tausig, 1986), social support is indicated by a two-item perceived strong tie support (i.e., perception of having enough close companions or friends). Prior
social support and change in social support have a main negative effect on the change in
depression over time. Prior social support also has an indirect effect on the change in
depression by suppressing the change in undesirable life events. Change in social support
mediates some effects of prior social support, prior undesirable life events, the change in
undesirable life events, and prior depression, which decrease the change in social support.
Furthermore, prior physical health has a positive association with current social support.
Two more studies use the three waves of data, and measure social support using the
foregoing two-item strong-tie support scale. One study (Lin and Ensel, 1989) focuses on
physical health. It fails to find a main effect of social support on physical symptoms at
24 Time 3. Social support at Time 2, however, does buffer the effects of stressors and
depression at Time 1. The second study (Ensel and Lin, 1991) explores depression. Social
support at Time 2 has a main negative effect on depression at Time 3. It also mediates the effect of stressors at Time 1 that decreases social support. The study fails to find evidence
for any moderating effect.
In addition, providing support and its health effects receives little attention. For example,
Krause and colleagues (Krause et al., 1999) examine a national sample of the elderly in
Japan. They measure emotional support provided to others based on two items (i.e., how
often respondents listen to people who wish to talk about worry or trouble, and how often
respondents encourage and comfort people experiencing hardship). Providing emotional
support is positively associated with self-reported health for both men and women. It also
mediates the positive health effect of religious practice, but only for men.
In summary, the above empirical studies focus on received support. They are concerned
more with mental than physical health outcomes. Most studies assume a social causation
explanation. They pay more attention to the main and moderating health effect of social
support than its mediating and indirect impact. The results of these studies are
inconsistent. There is more confirming than disconfirming evidence that social support
exerts a direct protective effect on health, mental health in particular. The significance of
that effect may vary with samples, outcomes, measures of social support,
sociodemographic groups, and even neighborhood contexts. Some studies demonstrate
that social support mitigates the effect of psychological resources and stressors, but more
25 studies do not. The importance of the moderating role of social support differs across
gender groups, statistical methods, and types of social support. A few studies on the
mediating function of social support report that social support may help explain some
health effects of sociodemographic and socioeconomic variables, psychological resources,
social integration, tie and network attributes, and precedent stressors. Furthermore, social
support may act as a precursor and affect health indirectly by influencing psychological
resources and reducing stressors. Longitudinal research designs are limited. As a result, the social selection argument receives very little attention. Such limited studies also report conflicting evidence. Aneshensel and Frerichs (1982) do not find an impact of depression on social support, while Lin and colleagues (Lin, 1986b, Tausig, 1986) find that better physical and mental health brings in more social support. In addition, providing support seems to have a direct or mediating effect on health.
CONCLUSION
As this review suggests, social support has triggered a burgeoning multidisciplinary research literature, especially in the area of health during the last three decades. Social support initially arose as a post hoc explanation for the emerging relationships that linked social factors, especially relational factors to health and well-being. Since the appearance of the seminal works, scholars have made significant advances in exploring the substance and dimensions of social support, developing diverse measurement instruments, and examining its multiple functions in the social distribution of health using a variety of data.
However, they have accumulated mixed evidence. Further efforts are needed to clarify and expand our current understanding of social support.
26
Social support is a unique social concept. As is the case with relatively new concepts in
social sciences, social support has been defined in diverse ways. The intellectual value of
a concept is evaluated not by its widening meaning or its potential role as a panacea, but
by its uniqueness and originality. Rather than going as far as Barrera (1986) in proposing
the abandonment of the general concept of social support, we suggest a rigorous strategy
in which future studies should define social support by its precise nature and the supply
of resources from network members, and separate it from its structural preconditions and
functional consequences. The priority of a reliable and valid social support scale was
recognized decades ago (Dean and Lin, 1977). As the reviewed empirical studies
illustrate, the indicators of social support were still quite diverse, probably due to the use of secondary data and post hoc measurements (Berkman, 1984). A strict definition may
help us overcome such inconsistency in operational measurements of social support and
empirical results.
Social support is a multidimensional factor in its intrinsic features. More theoretical and
empirical attention has been paid to received support than providing or reciprocal support.
Note that providing or reciprocal support influences health through different mechanisms
than received support. Among the literature on received support, there are more studies
on perceived than actual support, and on emotional than instrumental or other types of
support. Different kinds of support appear to be outcomes of disparate network-based
preconditions. Perceived and emotional support seem to have stronger explanatory power
in the social distribution of health than other types. To achieve a more complete picture
27 of social support, such multiple kinds of support concepts and measures need to be simultaneously subjected to a rigorous empirical test in order to distinguish their network-based antecedents and further compare their effects on specific health outcomes.
Social support is a distinctive network-based factor. Its precise definition is crucial for a coherent and comprehensive understanding of the general literature from a social network perspective. Various network-based concepts, including social support, are different constructs. Social support is expected to be a meaningful pathway that links other prominent network-derived concepts to our outcomes of interests. Some of the above reviewed empirical studies use other network terms as proximate measures of social support, but they do not examine social support directly. Their results in making stronger causal inferences regarding social support are limited. Future studies should make measure network concepts independently, and examine their relationships systematically in a causal sequence. Thus the urgent task in the area of health research is to examine how divergent types of social support mediate the effect of dissimilar network-based antecedents. The application of network analysis to social support research is undoubtedly a promising direction (Hall and Wellman, 1985; Wellman, 1981). The caveat is that social support should be captured more accurately through support-related network instruments than by general network instruments (Bearman and Parigi, 2004).
Social support is dynamic over time rather than being a constant feature (Dean and Lin,
1977; Pearlin, 1985). Most empirical studies are still cross-sectional, which leaves us questioning the robustness of their results. We are also aware of limited information
28 about, for example, how health and well-being shape the availability or mobilization of social support (Thoits, 1995), or how social support and its change may be in a reciprocal causal relationship with the change of other network-based terms. Refined longitudinal research designs are therefore needed to disentangle these complicated causality puzzles.
Finally, social support goes beyond its traditional function as a stress buffer, and plays multiple roles in the social organization of health and illness. It may protect health directly, or indirectly by reducing other health risks. It may mediate and moderate health effects of other determinants. There is further but mixed evidence for its direct and moderating effects, and fewer but also conflicting findings for its mediating and direct effect. For a thorough understanding of social dynamics through which social support maintains or changes health status, future studies should explore various models simultaneously in single studies as far as their data allow, and report all relevant results, either confirming or disconfirming.
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